Managing Chronic Constipation in Aged Care: A Comprehensive Guide

Chronic constipation is a frequent and often distressing condition affecting many older adults living in residential aged care facilities. Characterised by infrequent bowel movements, hard stools, and discomfort during defecation, this condition not only diminishes the quality of life but can also complicate existing health issues. Managing this ailment effectively requires a comprehensive understanding of its causes, which often include medication side effects and lifestyle factors.

This guide offers an in-depth look at various strategies to manage chronic constipation in aged care, emphasising a blend of both pharmacological treatments and non-pharmacological approaches to foster better patient outcomes and enhance their day-to-day wellness.

Understanding Chronic Constipation

Chronic constipation is a prevalent condition among the elderly, particularly those in residential aged care. It is characterised by infrequent bowel movements, typically fewer than three times per week, and may involve other symptoms such as hard stools, straining, a sensation of incomplete evacuation, abdominal pain, and bloating. These symptoms can significantly impact the quality of life and require effective management strategies.

Medication-Related Constipation

Medication-related constipation is a common issue in aged care, where many residents are on multiple medications due to various health conditions. Certain medications have a higher propensity to cause or worsen constipation, and understanding these can help in managing and preventing this uncomfortable condition.

Common Medications that Cause Constipation

Opioids: Widely used for pain management, opioids like oxycodone and morphine significantly reduce gastrointestinal motility, leading to constipation. Symptoms of opioid-induced constipation include hard stools, straining, and a sensation of incomplete evacuation. Preventative measures, such as the concurrent use of stimulant laxatives (e.g., senna or bisacodyl) and osmotic laxatives (e.g., macrogol), are recommended at the start of opioid therapy to mitigate constipation.
Tricyclic Antidepressants
Anticholinergic Agents
Iron Supplements: Supplements like ferrous sulphate are notorious for causing constipation and darkening of the stools. Iron polymaltose is a preferable alternative as it is less likely to cause gastrointestinal side effects.
Antacids: Those containing calcium carbonate or aluminium hydroxide can lead to constipation. An alternative, such as calcium citrate, is less likely to have this effect and may be a better option for individuals prone to constipation.
Calcium Channel Blockers
Antipsychotics
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Bismuth

Managing Severe Cases

In cases where conventional laxatives are insufficient, particularly with opioid-induced constipation, more intensive treatments may be necessary:

Glycerol Suppository and Enemas: For immediate relief in severe cases, options like glycerol suppositories or small-volume enemas can be effective.
Methylnaltrexone (Relistor): This opioid receptor antagonist is used particularly in palliative care settings to counteract opioid-induced constipation when other treatments fail. It can trigger a bowel movement within minutes of administration and is used when other measures are ineffective.

Prucalopride (Resotrans): This medication enhances gastrointestinal motility and is used when other treatments do not provide relief. If no benefit is observed within four weeks, its use should be discontinued.

Non-Pharmacological Approaches

Incorporating natural remedies into the management of chronic constipation can be highly effective, particularly in the elderly who may be sensitive to pharmacological treatments. Key elements such as increasing dietary fibre, fluid intake, and physical activity form the cornerstone of preventative therapy.

Increasing dietary fibre is a well-established approach to alleviating constipation. Fibre supplements like psyllium, and natural sources such as prunes and kiwifruit, play a crucial role in improving bowel regularity. A recent study illustrated the effectiveness of these dietary interventions by comparing the effects of daily intake of two green kiwifruits, 100g of prunes, or 21g of psyllium over four weeks. The results showed significant improvements in stool consistency and frequency of complete spontaneous bowel movements in all groups, with notable reductions in straining.

Psyllium, a type of bulk-forming fibre found in products like Metamucil, has water-holding and gel-forming properties that help increase stool bulk and soften it, making it easier to pass. Despite its effectiveness, it can sometimes lead to adverse events such as bloating and gas, although these are generally manageable with proper hydration.

Prunes, or dried plums, are another effective natural remedy for constipation. They not only provide fibre but also contain sorbitol—a natural laxative that increases stool water content and volume. This dual action makes prunes especially beneficial for constipation relief, contributing to softer stools and more regular bowel movements.

Kiwifruit is particularly beneficial for those who suffer from constipation with associated bloating. It offers both fibre and antioxidant benefits, helping to reduce abdominal discomfort and improve overall digestive health. Kiwifruits are also low in fermentable sugars, which means they are less likely to cause gas and bloating compared to other fruits. The study noted that kiwifruit consumption led to significant improvements in bloating, making it an excellent choice for individuals sensitive to other fibre sources.

Adequate hydration is essential when increasing fibre intake as it aids in the proper function of dietary fibre, helping to facilitate smoother bowel movements. Ensuring elderly patients consume sufficient fluids throughout the day can prevent the dehydration that often exacerbates constipation.

Regular physical activity helps stimulate intestinal motility and has been shown to be beneficial in maintaining regular bowel movements. Even light exercises, such as walking or gentle stretching, can significantly improve symptoms of constipation in the elderly.

These natural approaches, when combined with a balanced diet and adequate hydration, form a robust strategy for managing chronic constipation in aged care settings. They offer a safe, effective, and well-tolerated alternative to pharmacological treatments, particularly for elderly patients who may be prone to side effects from medications.

Medication for Constipation

Fibre Supplements

Bulk-forming supplements are a fundamental type of laxative recommended for managing chronic constipation. These supplements, which include psyllium (Metamucil), wheat dextrin (Benefiber), ispaghula husk (Fybogel), sterculia (Normafibe), and sterculia/frangula (Normacol Plus), work by increasing the bulk of stools. This action helps to distend the colon and promote natural peristaltic movement.

Fibre supplements need to be taken with sufficient fluids to prevent side effects such as bloating, cramping, or even bowel obstruction. While very effective for long-term management, bulk-forming laxatives are not suitable for immediate relief as their effects can take several days to manifest.

Stimulant Laxatives

Stimulant laxatives, such as senna and bisacodyl, increase the peristaltic activity of the intestines, thus speeding up bowel movements. These are particularly useful for more immediate relief of constipation. Oral forms typically take about 6 to 10 hours to work, while suppositories, such as those containing bisacodyl (Dulcolax), can act within 15 to 60 minutes. Despite concerns, there is no convincing evidence suggesting that long-term use of stimulant laxatives leads to significant colon issues.

Osmotic Laxatives

Osmotic laxatives, including lactulose (Actilax, Dulose, Duphalac), sorbitol (Sorbilax, Sorbisol), and macrogol (Movicol, Osmolax), function by drawing water into the intestinal lumen. This process helps soften the stools and makes them easier to pass. While effective, these laxatives can cause side effects such as bloating, gas, and cramping, particularly when first starting treatment. Care should be taken with lactulose if the individual’s fluid intake is not adequate.

Saline Laxatives

Saline laxatives like Epsom Salts are fast-acting and effective but should be used cautiously due to the risk of electrolyte disturbances, especially if used regularly or in high doses.

Stool Softeners

Stool softeners, such as docusate sodium (Coloxyl), liquid paraffin (Agarol, Parachoc), and poloxamer (Coloxyl Drops), are typically used to prevent constipation rather than treat it once it has established. They work by moistening the stool, easing its passage through the bowel. Liquid paraffin should not be taken before lying down due to the risk of aspiration. Stool softeners are often used in combination with stimulant laxatives for a more effective treatment approach.

Enemas and Suppositories

Enemas and suppositories are reserved for severe cases, such as faecal impaction, or when other laxatives have failed to produce the desired effect. They provide rapid relief, with products like Bisacodyl enema (Bisalax) working within 5 to 15 minutes. However, they should not be used regularly as a routine treatment for constipation due to the potential for dependency and disruption of natural bowel function.

Overall, the choice of laxative should be guided by the severity and nature of the constipation, the individual’s overall health, and any coexisting medical conditions. Regular monitoring and adjustment of the treatment regimen are crucial to ensure safety and effectiveness in managing constipation, particularly in the elderly population.

Constipation FAQs

What causes constipation in the elderly?

Constipation in elderly individuals often results from a combination of factors. These include physiological changes due to ageing, such as decreased gut motility and changes in the gastrointestinal tract. Medication side effects are also a major contributor, particularly from medications such as opioids, anticholinergics, and certain types of antidepressants. Additionally, lifestyle factors like reduced physical activity, inadequate hydration, and low dietary fibre intake can significantly influence bowel regularity in the elderly.

How can medication-related constipation be managed?

Managing medication-related constipation involves several strategies. Firstly, identifying and adjusting the medications that may be causing constipation is crucial. This might mean switching to a different medication or adjusting the dosage. Secondly, integrating a regimen of appropriate laxatives, such as osmotic or stimulant laxatives, can alleviate symptoms. Lastly, incorporating non-pharmacological approaches like increasing dietary fibre, ensuring adequate hydration, and encouraging gentle physical activity can help mitigate the effects of these medications.

What are the best practices for using laxatives in the elderly?

When using laxatives to treat constipation in the elderly, it is important to choose the type of laxative that best suits the individual’s specific needs and medical profile. Osmotic laxatives are generally safe and effective for long-term use and are good for softening the stool. Stimulant laxatives are useful for more immediate relief but should be used sparingly to avoid dependency and potential disruption to the colon’s natural function. It’s also vital to ensure adequate fluid intake when using bulk-forming laxatives to prevent worsening constipation. Regular monitoring by healthcare providers is essential to adjust the treatment plan as needed and to manage any side effects.

How long does it typically take for laxatives to work?

The onset of action for laxatives varies depending on the type. For instance, bulk-forming laxatives may take several days to be effective as they work by gradually increasing the bulk of the stool, which stimulates bowel movements. Osmotic laxatives may take a few hours to a couple of days to work, as they draw water into the intestines to soften the stools and make them easier to pass. Stimulant laxatives typically act more quickly, often within 6 to 12 hours, making them suitable for acute constipation relief. Understanding these timelines is crucial for managing expectations and planning treatment in a way that maximises comfort and efficacy.

What should be considered when choosing a laxative for an elderly patient?

When selecting a laxative for an elderly patient, several factors should be considered to ensure both safety and effectiveness. The patient’s overall health, typical bowel patterns, and existing medical conditions should guide the choice of laxative. For example, patients with chronic conditions like heart or kidney disease may need to avoid certain types of laxatives that can affect electrolyte balance. The patient’s current medication regimen should also be reviewed to avoid potential interactions. Personal preferences and lifestyle should also be taken into account to ensure the patient is comfortable and compliant with the treatment plan.

Key Takeaways

Tailored treatment strategies are essential for effective management of constipation in aged care, considering individual causes and factors
Combination of pharmacological and non-pharmacological methods enhances overall effectiveness
Importance of fibre in diet for improving bowel regularity and reducing bloating
Regular medication reviews to adjust or change medications that cause constipation
Appropriate selection of laxatives based on individual needs and conditions
Proactive management with laxatives for patients on constipation-inducing medications like opioids
Continuous safety monitoring and adjustment of treatment plans as needed
Education and communication with caregivers and patients to empower and inform them about managing constipation

Summary

Managing chronic constipation effectively in aged care enhances the well-being and quality of life of the elderly. A multi-faceted approach that includes dietary modifications, appropriate use of medications, and lifestyle changes is essential for optimal management of this common condition.

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